Liver Imaging Reporting and Data System Ultrasound Surveillance (LI-RADS US Surveillance) is a standardized system with recommendations for imaging technique, interpretation and reporting for surveillance of hepatocellular carcinoma (HCC) using unenhanced ultrasound in patients at high risk for developing HCC. As a surveillance tool, it is not intended to diagnose HCC, which requires dynamic assessment with contrast-enhanced studies. See: LI-RADS (overview).
The current version is LI-RADS US Surveillance v2024 Core.
On this page:
Usage
Patient selection
Populations at risk for HCC that LI-RADS US Surveillance is recommended for include
adult patients with cirrhosis of any etiology
adult patients with chronic hepatitis B virus infection, regardless of cirrhosis status
subsets of adults with chronic Hepatitis C virus infection regardless of cirrhosis status
subsets of adults with MAFLD regardless of cirrhosis status
Surveillance is not recommended for patients with Child-Pugh C cirrhosis, not eligible for liver transplantation, or patients with <1-2 years life expectancy and not able to be treated with liver transplantation or directed therapies.
If alpha-fetoprotein (AFP) levels are elevated or increasing over time, diagnostic workup with multiphase contrast-enhanced CT or MRI may be warranted, regardless of US findings.
Algorithm
Recommended algorithm
determine if patient is high risk for HCC (if not, then do not apply LI-RADS)
identify and categorize observation(s)
apply visualization score
Terminology
LI-RADS define an "observation" as a distinctive area compared to background liver. Focal abnormalities are not referred to as lesions or nodules.
Classification
LI-RADS US surveillance category
Categories
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US-1 negative
no observation or definitely benign observation.
examples of definitely benign observations include: simple hepatic cyst, focal fat sparing adjacent to gallbladder fossa, or previously confirmed hemangioma
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US-2 sub threshold
observations <10 mm, not definitely benign
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US-3 positive
observations ≥10 mm, not definitely benign, including areas of parenchymal distortion, or new hepatic or portal vein thrombus
example of parenchymal distortions include: ill-defined heterogenous area, refractive edge shadows, loss of normal hepatic architecture (e.g. capsular retraction)
Tiebreaking rules
If there is uncertainty of an observation category, upgrade category reflecting greater suspicion (example: if unsure between US-2 or US-3, pick US-3).
LI-RADS US surveillance visualization score
Assessment of technical quality of the study can be categorized as:
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VIS-A: no or minimal limitations
limitations if any present are unlikely to affect sensitivity
example: liver completely or near completely visualized, with little beam attenuation/shadowing
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VIS-B: moderate limitations
limitations that may obscure small (<10 mm) observations
example: moderate beam attenuation with some portions of liver or diaphragm not visualized
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VIS-C: severe limitations
limitations that significantly limits detection of observations
example: severe beam attenuation with most (>50%) of either liver lobe not visualized
Treatment and prognosis
Suggested management:
US-1 (negative): repeat US in 6 months
-
US-2 (sub threshold): repeat US in 3-6 months up to 2 times
if observation remains <10 mm or not visualized on follow-up twice, then the observation can be recategorised as US-1 and return to 6 monthly surveillance
US-3 (positive): evaluate with multi-phase CT, MRI or CEUS
-
AFP positive without US-3 observation: evaluate with multi-phase CT or MRI
in the absence of a US-3 observation, CEUS is unlikely to be of use
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VIS-C (severe limitations):
consider alternative surveillance modality (e.g. CT or MRI), or;
repeat US within 3 months 1 time. If still VIS-C, then consider other surveillance method (e.g. CT or MRI)
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